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Zhu B, Zhao F, Qin X, Jiang H, Yao Z. Multiple stress fractures: A case report and discussion. Radiol Case Rep 2024; 19:3656-3660. [PMID: 38983284 PMCID: PMC11228661 DOI: 10.1016/j.radcr.2024.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 07/11/2024] Open
Abstract
Stress fracture is the result of bone destruction with prolonged and repetitive loading. It usually occurs among various groups, including athletes, military recruits, and others. Early stress fractures often undergo undiagnosed or misdiagnosed because of atypical symptoms and effective medical examination. Here, we report a rare clinical case about the multiple stress fractures in one adolescent. Expect for the pathological biopsy, it hardly gets confirm diagnosis. With the increasing population of sports lover, healthcare institutions should be enhanced their understanding of stress fractures and enable effective management at an early stage.
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Affiliation(s)
- Bitao Zhu
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Fei Zhao
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Xiabing Qin
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Heng Jiang
- Department of anesthesiology, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Zhongjun Yao
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
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2
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George ERM, Sheerin KR, Reid D. Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports Med 2024:10.1007/s40279-024-02051-y. [PMID: 39141251 DOI: 10.1007/s40279-024-02051-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 08/15/2024]
Abstract
Tibial bone stress injuries (BSIs) are common among long-distance runners. They have a high recurrence rate, and complexity emerges in the wider management and successful return to running. Following a tibial BSI, a critical component of complete rehabilitation is the successful return to running, and there is a lack of consistency or strong evidence to guide this process. The objectives of this review were to outline the criteria used in clinical decision-making prior to resuming running, and to establish evidence-based guidelines for the return to running process following a tibial BSI. Electronic databases including MEDLINE, CINAHL, Scopus, SPORTDiscus and AMED were searched for studies that stated criteria or provided guidelines on the objectives above. Fifty studies met the inclusion criteria and were included. Thirty-nine were reviews or clinical commentaries, three were retrospective cohort studies, two were randomised controlled trials, two were pilot studies, one was a prospective observational study, and three were case studies. Therefore, the recommendations that have been surmised are based on level IV evidence. Decisions on when an athlete should return to running should be shared between clinicians, coaches and the athlete. There are five important components to address prior to introducing running, which are: the resolution of bony tenderness, pain-free walking, evidence of radiological healing in high-risk BSIs, strength, functional and loading tests, and the identification of contributing factors. Effective return to running planning should address the athlete's risk profile and manage the risk by balancing the athlete's interests and reinjury prevention. An individualised graduated return to running programme should be initiated, often starting with walk-run intervals, progressing running distance ahead of speed and intensity, with symptom provocation a key consideration. Contributing factors to the initial injury should be addressed throughout the return to run process.
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Affiliation(s)
- Esther R M George
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.
- InForm Physio, Silverstream, New Zealand.
| | - Kelly R Sheerin
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Duncan Reid
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
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3
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Tsukahara Y, Kuribayashi C, Akiyama E. Influence of Body Weight Measurement Frequency on the Bone Health of Female Athletes. RESEARCH QUARTERLY FOR EXERCISE AND SPORT 2024:1-7. [PMID: 39025043 DOI: 10.1080/02701367.2024.2378850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 07/06/2024] [Indexed: 07/20/2024]
Abstract
Purpose: Athletes struggle with bone stress injuries despite the many risk factors reported in previous studies. However, the relationship between body weight measurement frequency and risk of stress fractures has yet to be investigated. Thus, the purpose of this study is to seek the link between body weight measurement frequency and the occurrence of stress fractures. Method: This cross-sectional study included female athletes who were requested to fill out an anonymous online survey regarding their personal background, including the history of amenorrhea and stress fractures. In addition, the frequency at which they measured their body weight and composition and whether they had to report the same to their coaches and seniors were asked. Results: A total of 172 collegiate female athletes for 28 different types of sports participated in this study. Among the included athletes, 35.7% had a history of amenorrhea, whereas 29.7% had a history of stress fractures. A total of 57.0% of the athletes answered that in their team, they measure their body weight on a regular basis, and 33.1% of the athletes answered that they reported the data to their coaches. Logistic regression analysis revealed that those who measured their body weight at least once a day had a higher risk of sustaining stress fractures than did those who measured their body weight less than once a day (OR = 2.36, 95% CI 1.06-5.27, p = .04). Conclusion: Body weight measurement frequency was associated with the risk of stress fractures in female collegiate athletes.
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Sax AJ. Osseous Stress Injuries: Treatment Algorithms and Return to Play. Semin Musculoskelet Radiol 2024; 28:130-138. [PMID: 38484765 DOI: 10.1055/s-0043-1778030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Osseous stress injuries are common in athletes. Specifically, lower extremity injuries are prevalent in running athletes and upper extremity injuries are prevalent in throwing athletes. Such injuries are suspected when there is focal bone tenderness and increased pain with the inciting activity. In elite athletes, osseous stress injuries are a relatively common culprit in lost play time. Thus rapid diagnosis and treatment is imperative to expedite return to play (RTP). The radiologist's role in these cases is not only for diagnosis, but also to grade the injury, which has implications in determining a treatment regimen. The high sensitivity and specificity of magnetic resonance imaging is thus the preferred imaging modality. This article discusses common osseous stress injuries, the imaging findings, and how different treatment regimens affect RTP.
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Affiliation(s)
- Alessandra J Sax
- The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island
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5
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Ramon S, Lucenteforte G, Alentorn-Geli E, Steinbacher G, Unzurrunzaga R, Álvarez-Díaz P, Barastegui D, Grossi S, Sala E, Martinez-De la Torre A, Mangano GRA, Cuscó X, Rius M, Ferré-Aniorte A, Cugat R. Shockwave Treatment vs Surgery for Proximal Fifth Metatarsal Stress Fractures in Soccer Players: A Pilot Study. Foot Ankle Int 2023; 44:1256-1265. [PMID: 37905784 DOI: 10.1177/10711007231199094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
BACKGROUND To compare the clinical, radiologic, and functional outcomes between shockwave and operative treatments for proximal fifth metatarsal stress fractures in soccer players in a pilot study. METHODS Between 2017 and 2019, 18 soccer players with fifth metatarsal stress fractures attended at Mutualidad de Futbolistas Españoles-Delegación Catalana were included. Patients were randomly assigned into 2 groups receiving either surgery with an intramedullary screw (group 1) or high-energy focused extracorporeal shockwave treatment (group 2 performed once a week for 3 weeks using 2000 impulses at an energy flux density of 0.21 mJ/mm2 and 4 Hz frequency). Clinical (pain), radiologic (bone healing), and functional (Tegner Activity Scale and American Orthopaedic Foot & Ankle Society [AOFAS] ankle-hindfoot scales) outcomes before and after receiving the treatment were compared between both groups. In addition, ability and time to return to play was also compared between groups. RESULTS No patients were lost to follow-up. There were no statistically significant differences at last follow-up between surgery and extracorporeal shockwave treatment for bone healing, pain relief, AOFAS ankle-hindfoot score, Tegner score, and time return to play. No complications were reported in either of the 2 groups. CONCLUSION In this pilot study, extracorporeal shockwave treatment and operative treatment were found to be equally effective at reducing pain, achieving bone healing, and allowing the soccer players to return to play after proximal fifth metatarsal stress fractures. This study suggests that ESWT may be a good option for the management of proximal fifth metatarsal stress fractures in soccer players. If this approach proves successful in larger trials, the shockwave approach might help avoid known complications of the surgical treatment like wound problems, nerve injury, and hardware intolerance. Further investigations with larger sample size should be conducted in order to confirm the present conclusions. LEVEL OF EVIDENCE Level II, therapeutic, pilot randomized controlled trial.
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Affiliation(s)
- Silvia Ramon
- Department of Physical Medicine and Rehabilitation, Hospital Quirónsalud Barcelona, Spain
- Fundación García-Cugat, Barcelona, Spain
| | - Giacomo Lucenteforte
- Policlinico Vittorio Emanuele, Università degli Studi di Catania, Catania, Italy
- Isokinetic Medical Group, FIFA Medical Centre of Excellence, Education & Research Department, Bologna, Italy
| | - Eduard Alentorn-Geli
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Gilbert Steinbacher
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
| | - Rocío Unzurrunzaga
- Department of Physical Medicine and Rehabilitation, Hospital Quirónsalud Barcelona, Spain
- Fundación García-Cugat, Barcelona, Spain
- Department of Physical Medicine and Rehabilitation, MC Mutual, Barcelona, Spain
| | - Pedro Álvarez-Díaz
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - David Barastegui
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Sebastián Grossi
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
| | - Esther Sala
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Escola Universitària Gimbernat, Universitat Autònoma de Barcelona, Sant Cugat del Vallès, Barcelona, Spain
| | - Adrián Martinez-De la Torre
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | | | - Xavier Cuscó
- Fundación García-Cugat, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Marta Rius
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
| | - Alfred Ferré-Aniorte
- Fundación García-Cugat, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Ramón Cugat
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
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Kawashima I, Hiraiwa H, Ishizuka S, Oba H, Sakaguchi T, Idota M, Kawai R, Tsukahara T, Imagama S. Displaced tibial and fibular stress fractures in a female elite pole-vaulter with menstrual dysfunction, vitamin D deficiency, and high serum pentosidine. J Orthop Sci 2023; 28:1513-1517. [PMID: 34794859 DOI: 10.1016/j.jos.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/31/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Itaru Kawashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Hideki Hiraiwa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Shinya Ishizuka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takefumi Sakaguchi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masaru Idota
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Ryosuke Kawai
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Takashi Tsukahara
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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7
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Morimoto S, Iseki T, Shimmyo A, Tachibana T. Stress fracture of the lateral talar process in a male basketball player treated by percutaneous screw fixation: A case report. J Orthop Sci 2023; 28:1555-1560. [PMID: 34801344 DOI: 10.1016/j.jos.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/19/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Shota Morimoto
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan.
| | - Tomoya Iseki
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan
| | - Airi Shimmyo
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan
| | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan
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8
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Malliaropoulos N, Bikos G, Tsifountoudis I, Alaseirlis D, Christodoulou D, Padhiar N, Maffulli N. Therapeutic ultrasound related pain threshold in elite track & field athletes with tibial bone stress injuries. Surgeon 2023; 21:225-229. [PMID: 35927163 DOI: 10.1016/j.surge.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Tibial stress injuries are challenging in terms of early diagnosis, management strategy, and safe return-to-play. In the present study, pain production associated with the application of therapeutic ultrasound (TUS) was used as a primary diagnostic tool to assess tibial bone stress injuries, and the sensitivity of this procedure was compared with Magnetic Resonance Imaging (MRI). SUBJECT AND METHODS The study was designed as a retrospective analysis of prospectively collected data on tibial bone stress injuries in elite Track and field athletes attending the National Track and Field Athletics Centre in Thessaloniki, Greece, in the period 1995-2007. All patients underwent evaluation by TUS, and the sensitivity of the procedure was compared with MRI. RESULTS Four of 29 athletes showed a positive TUS examination for stress injury while MRI showed normal findings. Additionally, 5 athletes evidenced MRI findings typical of a tibial bone stress injury, while TUS evaluation was negative. Using MRI as the standard, TUS displayed a sensitivity of 79.2%. CONCLUSION Therapeutic ultrasound is a reproducible modality with satisfactory reliability and sensitivity related to MRI, and could represent a useful tool for clinicians to primarily assess suspected tibial bone stress injuries in high qualification Track and Field athletes.
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Affiliation(s)
- Nikolaos Malliaropoulos
- Sports and Exercise Medicine Clinic, Asklipiou, Thessaloniki, Greece; Sports Clinic, Rheumatology Department, Barts Health NHS Trust, London, UK; Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK.
| | - Georgios Bikos
- Euromedica-Arogi Rehabilitation Clinic, Pylaia, Thessaloniki, Greece.
| | | | - Dimosthenis Alaseirlis
- General Clinic-Euromedica, Thessaloniki, Greece; First Department of Orthopaedic Surgery, Aristotle University of Thessaloniki, Greece.
| | | | - Nat Padhiar
- Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK; London Sports Care, BMI London Independent Hospital, London, UK.
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK; First Department of Orthopaedic Surgery, Aristotle University of Thessaloniki, Greece; Department of Orthopaedics, School of Medicine, Surgery and Dentistry, Salerno, Italy; Institute of Science and Technology in Medicine, Keele University School of Medicine, Stoke on Trent, United Kingdom.
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9
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Sneag DB, Abel F, Potter HG, Fritz J, Koff MF, Chung CB, Pedoia V, Tan ET. MRI Advancements in Musculoskeletal Clinical and Research Practice. Radiology 2023; 308:e230531. [PMID: 37581501 PMCID: PMC10477516 DOI: 10.1148/radiol.230531] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 08/16/2023]
Abstract
Over the past decades, MRI has become increasingly important for diagnosing and longitudinally monitoring musculoskeletal disorders, with ongoing hardware and software improvements aiming to optimize image quality and speed. However, surging demand for musculoskeletal MRI and increased interest to provide more personalized care will necessitate a stronger emphasis on efficiency and specificity. Ongoing hardware developments include more powerful gradients, improvements in wide-bore magnet designs to maintain field homogeneity, and high-channel phased-array coils. There is also interest in low-field-strength magnets with inherently lower magnetic footprints and operational costs to accommodate global demand in middle- and low-income countries. Previous approaches to decrease acquisition times by means of conventional acceleration techniques (eg, parallel imaging or compressed sensing) are now largely overshadowed by deep learning reconstruction algorithms. It is expected that greater emphasis will be placed on improving synthetic MRI and MR fingerprinting approaches to shorten overall acquisition times while also addressing the demand of personalized care by simultaneously capturing microstructural information to provide greater detail of disease severity. Authors also anticipate increased research emphasis on metal artifact reduction techniques, bone imaging, and MR neurography to meet clinical needs.
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Affiliation(s)
- Darryl B. Sneag
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
| | - Frederik Abel
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
| | - Hollis G. Potter
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
| | - Jan Fritz
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
| | - Matthew F. Koff
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
| | - Christine B. Chung
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
| | - Valentina Pedoia
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
| | - Ek T. Tan
- From the Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021 (D.B.S., F.A., H.G.P., M.F.K.,
E.T.T.); Department of Radiology, New York University Grossman School of
Medicine, New York, NY (J.F.); Department of Radiology, University of California
San Diego, La Jolla, Calif (C.B.C.); Radiology Service, Veterans Affairs San
Diego Healthcare System, La Jolla, Calif (C.B.C.); and Department of Radiology
and Biomedical Imaging, University of California San Francisco, San Francisco,
Calif (V.P.)
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10
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Popp KL, Outerleys J, Gehman S, Garrahan M, Rudolph S, Loranger E, Ackerman KE, Tenforde AS, Bouxsein ML, Davis IS. Impact loading in female runners with single and multiple bone stress injuries during fresh and exerted conditions. JOURNAL OF SPORT AND HEALTH SCIENCE 2023; 12:406-413. [PMID: 35218949 DOI: 10.1016/j.jshs.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/25/2021] [Accepted: 01/13/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND Bone stress injuries (BSIs) are common in female runners, and recurrent BSI rates are high. Previous work suggests an association between higher impact loading during running and tibial BSI. However, it is unknown whether impact loading and fatigue-related loading changes discriminate women with a history of multiple BSIs. This study compared impact variables at the beginning of a treadmill run to exertion and the changes in those variables with exertion among female runners with no history of BSI as well as among those with a history of single or multiple BSIs. METHODS We enrolled 45 female runners (aged 18-40 years) for this cross-sectional study: having no history of diagnosed lower extremity BSI (N-BSI, n = 14); a history of 1 lower extremity BSI (1-BSI, n = 16); and diagnosed by imaging, or a history of multiple (≥3) lower extremity BSIs (M-BSI, n = 15). Participants completed a 5-km race speed run on an instrumented treadmill while wearing an Inertial Measurement Unit. The vertical average loading rate (VALR), vertical instantaneous loading rate (VILR), vertical stiffness during impact via instrumented treadmill, and tibial shock determined as the peak positive tibial acceleration via Inertial Measurement Unit were measured at the beginning and the end of the run. RESULTS There were no differences between groups in VALR, VILR, vertical stiffness, or tibial shock in a fresh or exerted condition. However, compared to N-BSI, women with M-BSI had greater increase with exertion in VALR (-1.8% vs. 6.1%, p = 0.01) and VILR (1.5% vs. 4.8%, p = 0.03). Similarly, compared to N-BSI, vertical stiffness increased more with exertion among women with M-BSI (-0.9% vs. 7.3%, p = 0.006) and 1-BSI (-0.9% vs. 1.8%, p = 0.05). Finally, compared to N-BSI, the increase in tibial shock from fresh to exerted condition was greater among women with M-BSI (0.9% vs. 5.5%, p = 0.03) and 1-BSI (0.9% vs. 11.2%, p = 0.02). CONCLUSION Women with 1-BSI or M-BSIs experience greater exertion-related increases in impact loading than women with N-BSI. These observations imply that exertion-related changes in gait biomechanics may contribute to risk of BSI.
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Affiliation(s)
- Kristin L Popp
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA; Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA.
| | - Jereme Outerleys
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, MA 02138, USA
| | - Sarah Gehman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Margaret Garrahan
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Sara Rudolph
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Elizabeth Loranger
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Kathryn E Ackerman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA; Department of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, MA 02138, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA; Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Irene S Davis
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, MA 02138, USA
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11
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Shaw KA, Moreland CM, Hunt TJ, Barkley C, O'Brien F, Jackson KL. Femoral Neck Stress Fractures in Athletes and the Military. J Bone Joint Surg Am 2022; 104:473-482. [PMID: 35234724 DOI: 10.2106/jbjs.21.00896] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Femoral neck stress fractures (FNSFs) are an infrequent condition in athletic and military populations. ➤ A high index of suspicion with liberal use of magnetic resonance imaging (MRI) is vital for early recognition and treatment initiation. ➤ An associated hip effusion on MRI is a risk factor for an evolving stress injury and requires close assessment and consideration for repeat MRI. ➤ Stress reactions and stable, incomplete FNSFs (<50% of femoral neck width) can be treated nonsurgically. ➤ Surgical intervention is accepted for high-risk, incomplete (≥50% of femoral neck width), and complete FNSFs. ➤ Overall, there is a paucity of high-quality literature on the rates of return to activity following FNSF.
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Affiliation(s)
- K Aaron Shaw
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Colleen M Moreland
- Department of Orthopaedic Surgery, Womack Army Medical Center, Fort Bragg, North Carolina
| | - Tyler J Hunt
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Colleen Barkley
- Department of Physical Therapy, Moncrief Army Health Clinic, Fort Jackson, South Carolina
| | - Frederick O'Brien
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Keith L Jackson
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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12
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Tong X, Turunen MJ, Burton IS, Kröger H. Generalized Uncoupled Bone Remodeling Associated With Delayed Healing of Fatigue Fractures. JBMR Plus 2022; 6:e10598. [PMID: 35309868 PMCID: PMC8914151 DOI: 10.1002/jbm4.10598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 11/09/2022] Open
Abstract
Fatigue fractures in bones are common injuries with load‐bearing activities, during which the remodeling aimed at removing microdamage has been suggested to play a role in increasing related fracture risk. Much attention has been given to the uncoupling between osteoclastic bone resorption and osteoblastic osteogenesis in fatigue fracture cases; however, the underlying pathophysiologic mechanisms of impaired fracture healing are yet unknown. Here we report multiple fatigue fractures in a physically active woman receiving contraceptive pills for years. Her fracture healing was remarkably slow, although she has been otherwise healthy. The patient underwent bone biopsy of the iliac crest that showed remarkable peritrabecular fibrosis with increased osteoclastic bone resorption combined with relatively low bone formation. Analysis of bone biochemical composition revealed a more complex picture: First, notable declines in bone mineral content–based parameters indicating abnormal mineralization were evident in both cancellous and cortical bone. Second, there was elevation in mineral crystal size, perfection, and collagen maturity in her bone tissues from different anatomical sites. To our knowledge, this is the first report showing generalized uncoupling in bone remodeling, increased peritrabecular fibrosis, and bone compositional changes associated with delayed healing of fatigue fractures. These results may explain delayed healing of fatigue and stress fractures. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Xiaoyu Tong
- Kuopio Musculoskeletal Research Unit (KMRU), Clinical Research Centre, Institute of Clinical Medicine, University of Eastern Finland Kuopio Finland
| | - Mikael J Turunen
- Department of Applied Physics University of Eastern Finland Kuopio Finland
| | - Inari S Burton
- Kuopio Musculoskeletal Research Unit (KMRU), Clinical Research Centre, Institute of Clinical Medicine, University of Eastern Finland Kuopio Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), Clinical Research Centre, Institute of Clinical Medicine, University of Eastern Finland Kuopio Finland
- Department of Orthopaedics, Traumatology, and Hand Surgery Kuopio University Hospital Kuopio Finland
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13
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Klavas DM, Holderread BM, Liu J, Cosculluela PE. Bilateral Medial Malleolus Stress Fractures in a High School Athlete Treated With Open Reduction Internal Fixation. Cureus 2021; 13:e18186. [PMID: 34589372 PMCID: PMC8459807 DOI: 10.7759/cureus.18186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 12/02/2022] Open
Abstract
Pediatric medial malleolus stress fracture is a rare pathology and has limited data on management. The authors present a case of bilateral medial malleolus stress fracture treated with operative fixation followed by a course of immobilization and protected weight-bearing.
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Affiliation(s)
- Derek M Klavas
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
| | - Brendan M Holderread
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
| | - Jonathan Liu
- Department of Orthopedic Surgery, Brown University, Providence, USA
| | - Pedro E Cosculluela
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
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14
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Murakami R, Sanada T, Inagawa M, Yoshitomi H, Honda E, Fukai A, Iwaso H. Can low-intensity pulsed ultrasound (LIPUS) accelerate bone healing after intramedullary screw fixation for proximal fifth metatarsal stress fractures? A retrospective study. BMC Musculoskelet Disord 2021; 22:725. [PMID: 34425817 PMCID: PMC8383417 DOI: 10.1186/s12891-021-04611-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background Intramedullary screw fixation is considered the standard treatment for proximal fifth metatarsal stress fractures. Low-intensity pulsed ultrasound (LIPUS) is a well-known bone-healing enhancement device. However, to the best of our knowledge, no clinical study has focused on the effect of LIPUS for postoperative bone union in proximal fifth metatarsal stress fractures. This study aimed to investigate the effect of LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures. Methods Between January 2015 and March 2020, patients who underwent intramedullary screw fixation for proximal fifth metatarsal stress fractures were investigated retrospectively. All patients underwent intramedullary screw fixation using a headless compression screw with autologous bone grafts from the base of the fifth metatarsal. The time to restart running and return to sports, as well as that for radiographic bone union, were compared between groups with or without LIPUS treatment. LIPUS treatment was initiated within 3 weeks of surgery in all cases. Results Of the 101 ft analyzed, 57 ft were assigned to the LIPUS treatment group, and 44 ft were assigned to the non-LIPUS treatment group. The mean time to restart running and return to sports was 6.8 and 13.7 weeks in the LIPUS treatment group and was 6.2 and 13.2 weeks in the non-LIPUS treatment group, respectively. There were no significant differences in these parameters between groups. In addition, the mean time to radiographic bone union was not significantly different between the LIPUS treatment group (11.9 weeks) and the non-LIPUS treatment group (12.0 weeks). The rate of postoperative nonunion in the LIPUS treatment group was 0% (0/57), while that in the non-LIPUS treatment group was 4.5% (2/44). However, this difference was not statistically significant. Conclusions There were no statistically significant differences regarding the time to start running, return to sports, and radiographic bone union in patients with or without LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures. Therefore, we cannot recommend the routine use of LIPUS to shorten the time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures.
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Affiliation(s)
- Ryo Murakami
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, Kanagawa Prefacture, Japan.
| | - Takaki Sanada
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, Kanagawa Prefacture, Japan
| | - Miyu Inagawa
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, Kanagawa Prefacture, Japan
| | - Hiroki Yoshitomi
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, Kanagawa Prefacture, Japan
| | - Eisaburo Honda
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, Kanagawa Prefacture, Japan
| | - Atsushi Fukai
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, Kanagawa Prefacture, Japan.,Faculty of Medical Technology, Teikyo University, Tokyo, Japan
| | - Hiroshi Iwaso
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, Kanagawa Prefacture, Japan
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15
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[Stress fractures of the lower limbs]. DER ORTHOPADE 2021; 50:763-774. [PMID: 34415371 DOI: 10.1007/s00132-021-04139-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
Stress reactions and fractures represent an important differential diagnostic entity, especially in patients active in sports. The lower extremities have predilection sites for stress fractures, which require special treatment in the context of the underlying risk factors. Clinically, patients usually complain of stress-dependent pain in the affected region and sport activities are mostly limited or even impossible. The detection of acute stress fractures is usually missed by conventional X‑ray within the first 4-6 weeks. The gold standard diagnostic tool is magnetic resonance imaging (MRI). Depending on the location, a distinction must be made between low-risk and high-risk stress fractures. Low-risk fractures show a high healing rate after conservative treatment including load and stress reduction as well as avoiding risk factors. High-risk fractures can take a complicated course under conservative treatment measures and in some cases, surgical intervention is required.
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16
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Popp KL, Ackerman KE, Rudolph SE, Johannesdottir F, Hughes JM, Tenforde AS, Bredella MA, Xu C, Unnikrishnan G, Reifman J, Bouxsein ML. Changes in Volumetric Bone Mineral Density Over 12 Months After a Tibial Bone Stress Injury Diagnosis: Implications for Return to Sports and Military Duty. Am J Sports Med 2021; 49:226-235. [PMID: 33259223 DOI: 10.1177/0363546520971782] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone stress injuries (BSIs) occur in up to 20% of runners and military personnel. Typically, after a period of unloading and gradual return to weightbearing activities, athletes return to unrestricted sports participation or military duty approximately 4 to 14 weeks after a BSI diagnosis, depending on the injury location and severity. However, the time course of the recovery of the bone's mechanical competence is not well-characterized, and reinjury rates are high. PURPOSE To assess the bone microarchitecture and volumetric bone mineral density (vBMD) over 12 months after a tibial BSI diagnosis. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS We enrolled 30 female athletes from the local community (aged 18-35 years) with a tibial BSI (grade ≥2 of 4 on magnetic resonance imaging) for this prospective observational study. Participants completed a baseline visit within 3 weeks of the diagnosis. At baseline and 6, 12, 24, and 52 weeks after the BSI diagnosis, we collected high-resolution peripheral quantitative computed tomography scans of the ultradistal tibia (4% of tibial length) of the injured and uninjured legs as well as pain and physical activity assessment findings. RESULTS From baseline to 12 weeks after the diagnosis, total, trabecular, and cortical vBMD declined by 0.58% to 0.94% (P < .05 for all) in the injured leg. Total and trabecular vBMD also declined by 0.61% and 0.67%, respectively, in the uninjured leg (P < .05 for both). At 24 weeks, mean values for all bone parameters were nearly equivalent to baseline values, and by 52 weeks, several mean values had surpassed baseline values. Of the 30 participants, 10 incurred a subsequent BSI during the course of the study, and 1 of these 10 incurred 2 subsequent BSIs. Participants who suffered an additional BSI were younger and had a later age of menarche, a greater incidence of previous fractures, and lower serum parathyroid hormone levels (P < .05 for all). CONCLUSION Bone density declined in both the injured and the uninjured legs and, on average, did not return to baseline for 3 to 6 months after a tibial BSI diagnosis. The observed time to the recovery of baseline vBMD, coupled with the high rate of recurrent BSIs, suggests that improved return-to-sports and military duty guidelines may be in order.
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Affiliation(s)
- Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Kathryn E Ackerman
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sara E Rudolph
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fjola Johannesdottir
- Harvard Medical School, Boston, Massachusetts, USA.,Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Adam S Tenforde
- Harvard Medical School, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Chun Xu
- Biotechnology High Performance Computing Software Applications Institute, Department of Defense, Frederick, Maryland, USA
| | - Ginu Unnikrishnan
- Biotechnology High Performance Computing Software Applications Institute, Department of Defense, Frederick, Maryland, USA
| | - Jaques Reifman
- Biotechnology High Performance Computing Software Applications Institute, Department of Defense, Frederick, Maryland, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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17
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Bitenc-Jasiejko A, Konior K, Gonta K, Dulęba M, Lietz-Kijak D. Prophylaxis of Pain and Fractures within Feet in the Course of Osteoporosis: The Issue of Diagnosing. Pain Res Manag 2020; 2020:1391026. [PMID: 33312316 PMCID: PMC7719525 DOI: 10.1155/2020/1391026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/10/2020] [Accepted: 11/10/2020] [Indexed: 11/17/2022]
Abstract
Background Considering the enormous risk of fractures in the course of osteoporosis in the area of the feet, an important aspect of prophylaxis is periodic and, in special cases, ongoing monitoring of defects and deformations as well as pressure distribution. The purpose of this article is to indicate the role of the examination of posture and pressure distribution during standing, postural balance, and gait, in the prevention of fatigue fractures in the course of osteoporosis, based on the literature review and examples of patients. Methods The manuscript consists of two parts; it has a review-analytical character. The first part reviews the literature. The data were obtained using the MEDLINE (PubMed), as well as Cochrane and Embase databases. The database review was carried out focusing mainly on English-language publications, while taking into account the topicality of scientific and research works in the area of osteoporosis. The problem of multiaspects in the area of bone density was pointed out. Considering the above, in the second part, the authors analyzed 11 exemplary patients with osteoporosis, referring to the assessment of foot and lower limb defects using traditional posturological methods and including pedobarography to diagnostic procedures that are used in the assessment of pressure distribution, standing and moving, and an attempt to balance. Results Analysis of the research and scientific literature proved the lack of unambiguous diagnostic procedures of the locomotor system recommended for the prevention of fatigue fractures in the course of osteoporosis. The main diagnostic recommendations are imaging tests (most often X-ray), which are recommended in the case of specific clinical symptoms. The analysis of exemplary patients with osteoporosis showed numerous disorders in the distribution of pressure in the plantar part of the feet, which are related, among other things, with their individual defects and lower limbs. Conclusions Detailed posture diagnostics and gait estimation, along with the analysis of pressure distribution within the feet are a very important aspect of the prevention of structural degradation and fatigue fractures within the feet. An important postulate for further research and scientific work is the elaboration of the procedures that will serve the preventive diagnostics of the locomotor system, aimed at early detection of threats of fatigue fractures.
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Affiliation(s)
- Aleksandra Bitenc-Jasiejko
- Department of Propaedeutic, Physical Diagnostics and Dental Physiotherapy, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Krzysztof Konior
- Doctoral Study Department of Propaedeutic, Physical Diagnostics and Dental Physiotherapy, Pomeranian Medical University in Szczecin, Medical Center in Nowogard, Szczecin, Poland
| | - Kinga Gonta
- College of Physiotherapy in Wroclaw, Ortogenic Rehabilitation and Podology Center in Wroclaw, Wroclaw, Poland
| | - Magdalena Dulęba
- College of Physiotherapy in Wroclaw, Ortogenic Rehabilitation and Podology Center in Wroclaw, Wroclaw, Poland
| | - Danuta Lietz-Kijak
- Department of Propaedeutic, Physical Diagnostics and Dental Physiotherapy, Pomeranian Medical University in Szczecin, Szczecin, Poland
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18
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Ditmars FS, Ruess L, Young CM, Hu HH, MacDonald JP, Ravindran R, Thompson BP. MRI of tibial stress fractures: relationship between Fredericson classification and time to recovery in pediatric athletes. Pediatr Radiol 2020; 50:1735-1741. [PMID: 32809066 DOI: 10.1007/s00247-020-04760-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 05/18/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Tibial stress fractures are not uncommon in pediatric athletes. The severity of injury may be graded using magnetic resonance imaging (MRI). OBJECTIVE To determine whether Fredericson MRI grading of tibial stress fractures can differentiate times to recovery across different grades in pediatric athletes. MATERIALS AND METHODS A medical record search identified all athletes younger than 19 years old who had tibial stress fractures confirmed by MRI and were treated by sports medicine specialists in our clinic system over a 5-year period. Two pediatric radiologists graded MRI exams using the Fredericson system. Time to recovery (in days) was defined in four ways: pain onset to full participation, pain onset to zero pain, first treatment to full sport participation and first treatment to zero pain. Recovery times were compared to tibial stress fracture Fredericson MRI grade and to the use of a recovery device. RESULTS Thirty-eight pediatric athletes (age range: 7-18 years, mean: 15.4±2.2 years) had 42 tibial stress fractures while participating in 12 different sports. About half (55%) were track and/or cross-country athletes. The mean time from diagnosis to report of no pain for all patients was 55.6±5.0 days. We found no significant difference in time to recovery across stress fracture grade or with the use of a recovery device. CONCLUSION No differences were noted between Fredericson stress fracture grades and different time periods to recovery or between differences in recovery time and the return to full participation in sports, regardless of the use of assistive devices.
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Affiliation(s)
- Frederick S Ditmars
- Department of Radiology, ED 4, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205-2664, USA
| | - Lynne Ruess
- Department of Radiology, ED 4, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205-2664, USA.,Department of Radiology, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Cody M Young
- Department of Radiology, ED 4, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205-2664, USA.,Department of Radiology, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Houchun H Hu
- Department of Radiology, ED 4, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205-2664, USA
| | - James P MacDonald
- Department of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Reno Ravindran
- Department of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Benjamin P Thompson
- Department of Radiology, ED 4, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205-2664, USA. .,Department of Radiology, The Ohio State Wexner Medical Center, Columbus, OH, USA.
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19
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Affiliation(s)
- T Pelly
- Kingston Hospital, London, UK
| | - T Holme
- St George's Hospital, London, UK
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20
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Nye NS, Covey CJ, Pawlak M, Olsen C, Boden BP, Beutler AI. Evaluating an Algorithm and Clinical Prediction Rule for Diagnosis of Bone Stress Injuries. Sports Health 2020; 12:449-455. [PMID: 32762527 DOI: 10.1177/1941738120943540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI. HYPOTHESIS A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI. STUDY DESIGN Prospective cohort study. LEVEL OF EVIDENCE Level 3. METHODS A total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated. RESULTS Of the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance. CONCLUSION The optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making. CLINICAL RELEVANCE For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.
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Affiliation(s)
| | - Carlton J Covey
- Travis Family Medicine Residency, Travis Air Force Base, California
| | - Mary Pawlak
- 559th Trainee Health Squadron, JBSA-Lackland, Texas
| | - Cara Olsen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barry P Boden
- The Orthopaedic Center, a Division of CAO, Rockville, Maryland
| | - Anthony I Beutler
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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21
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Bisciotti GN, Volpi P, Alberti G, Aprato A, Artina M, Auci A, Bait C, Belli A, Bellistri G, Bettinsoli P, Bisciotti A, Bisciotti A, Bona S, Bresciani M, Bruzzone A, Buda R, Buffoli M, Callini M, Canata G, Cardinali D, Cassaghi G, Castagnetti L, Clerici S, Corradini B, Corsini A, D'Agostino C, Dellasette E, Di Pietto F, Enrica D, Eirale C, Foglia A, Franceschi F, Frizziero A, Galbiati A, Giammatei C, Landreau P, Mazzola C, Moretti B, Muratore M, Nanni G, Niccolai R, Orizio C, Pantalone A, Parra F, Pasta G, Patroni P, Pelella D, Pulici L, Quaglia A, Respizzi S, Ricciotti L, Rispoli A, Rosa F, Rossato A, Sannicandro I, Sprenger C, Tarantola C, Tenconi FG, Tognini G, Tosi F, Trinchese GF, Vago P, Zappia M, Vuckovich Z, Zini R, Trainini M, Chamari K. Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer). BMJ Open Sport Exerc Med 2019; 5:e000505. [PMID: 31673400 PMCID: PMC6797382 DOI: 10.1136/bmjsem-2018-000505] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2019] [Indexed: 12/19/2022] Open
Abstract
Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.
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Affiliation(s)
| | - Piero Volpi
- Humanitas Clinical Institute, Rozzano, Milano, Italy.,FC Internazionale Milano, Milano, Milano, Italy
| | - Giampietro Alberti
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | | | | | - Alessio Auci
- UOS Angiografia e Radiologia Interventistica, Ospedale delle Apuane, Massa Carrara, Massa Carrara, Italy
| | | | | | | | | | | | | | - Stefano Bona
- Humanitas Clinical Institute, Rozzano, Milano, Italy
| | | | | | - Roberto Buda
- Dipartimento di Scienze Biomediche e Neuromotorie, Università Bologna, Bologna, Italy
| | | | | | - Gianluigi Canata
- Ospedale Koelliker, Torino, Italy.,Istituto di Medicina dello Sport di Torino, Torino, Italy
| | | | | | | | | | | | | | | | | | | | | | - Cristiano Eirale
- Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Paris St Germain FC, Paris, France
| | - Andrea Foglia
- Physiotherapy, Studio Riabilita, Civitanova Marche, Italy
| | | | | | | | | | | | | | - Biagio Moretti
- Dipartimento di Scienze Mediche di Base, Neuroscienze e Organi di Senso, Università di Bari, Bari, Italy
| | | | - Gianni Nanni
- FIFA Medical Centre of Excellence, Bologna, Isokinetic Medical Group, Bologna, Italy.,Bologna FC, Bologna, Italy
| | | | | | - Andrea Pantalone
- Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti, Italy.,Ospedale SS Annunziata, Chieti, Italy
| | | | - Giulio Pasta
- Parma Calcio, Parma, Italy.,Studio Radiologico Pasta, Parma, Italy
| | | | | | - Luca Pulici
- FC Internazionale Milano, Milano, Milano, Italy
| | - Alessandro Quaglia
- Humanitas Clinical Institute, Rozzano, Milano, Italy.,FC Internazionale Milano, Milano, Milano, Italy
| | | | | | | | | | | | | | | | | | | | | | - Fabio Tosi
- FC Internazionale Milano, Milano, Milano, Italy
| | | | - Paola Vago
- Universita Cattolica del Sacro Cuore, Milano, Italy
| | | | | | - Raul Zini
- Villa Maria Cecilia, Cotignola, Italy
| | | | - Karim Chamari
- Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Research Lab, National Center of Science and Sports Medicine Tunis, Tunis, Tunisia
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22
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Yao YC, Huang TF. Femoral Supracondylar Stress Fracture in an Adult Marathon Runner: A Case Report. Curr Sports Med Rep 2019; 18:355-357. [PMID: 31596750 DOI: 10.1249/jsr.0000000000000636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Yu-Cheng Yao
- Taipei Veterans General Hospital, Taipei City, TAIWAN
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23
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Miller D, Marsland D, Jones M, Calder J. Early return to playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union but does not increase the risk of long-term non-union. Knee Surg Sports Traumatol Arthrosc 2019; 27:2796-2801. [PMID: 30167755 DOI: 10.1007/s00167-018-5104-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 08/10/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE 5th metatarsal stress fractures are frequently encountered in professional football. There is concern that early return to play following intra-medullary screw fixation may lead to an increased risk of delayed union. The purpose of the study was to assess whether an early return to play after surgical fixation of 5th metatarsal fractures in professional football players is a risk factor for delayed union and the effect of this on the ultimate clinical outcome. METHODS Retrospective review of prospectively collected data of a series of 37 professional football players following intramedullary screw fixation of 5th metatarsal stress fractures. End points included time of return to play and to radiological union of the fracture. RESULTS At a minimum follow-up of 24 months the mean return to play was 10.5 weeks and mean time to complete radiological union was 12.7 weeks. Return to play at 8 weeks or less resulted in a higher risk of delayed radiological union (24% at 3 months), but this neither prevented the athlete from continuing to play football nor did it affect the ultimate risk of non-union (3% overall). A re-fracture occurred in 1 patient (3%) at 10 months who previously had complete radiographic union at 9 weeks. CONCLUSION Intramedullary screw fixation of 5th metatarsal stress fractures leads to a predictable time of return to play and a low rate of non-union. If players return to play at 8 weeks or less a persistent line may be expected in up to a quarter of patients. However, if asymptomatic this radiological finding does not mean that athletes must avoid playing football as ultimately a good outcome is expected with low rates of non-union and refracture. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- David Miller
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.
| | - Daniel Marsland
- Royal Hampshire County Hospital, Romsey Rd, Winchester, SO22 5DG, UK
| | - Mary Jones
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK
| | - James Calder
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.,FORCE Sports Research Centre, Department of Bioengineering, Imperial College, South Kensington, London, SW7 2AZ, UK
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24
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Coslick AM, Lagaz SR, Deu RS. Protocol for 8-Week Return to Running after a Femoral Stress Reaction. PM R 2019; 11:904-907. [PMID: 30719846 DOI: 10.1002/pmrj.12117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/13/2018] [Accepted: 01/28/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Alexis M Coslick
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah R Lagaz
- Department of Athletics, Johns Hopkins University, Baltimore, MD
| | - Rajwinder S Deu
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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25
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Lohrer H, Malliaropoulos N, Korakakis V, Padhiar N. Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. PHYSICIAN SPORTSMED 2019; 47:47-59. [PMID: 30345867 DOI: 10.1080/00913847.2018.1537861] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.
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Affiliation(s)
- Heinz Lohrer
- a European SportsCare Network (ESN) - Zentrum für Sportorthopädie , Wiesbaden-Nordenstadt , Germany
| | | | - Vasileios Korakakis
- c Department of Rehabilitation , Aspetar, Orthopaedic and Sports Medicine Hospital , Doha , Qatar
| | - Nat Padhiar
- d William Harvey Research Institute, Centre for Sports & Exercise Medicine , Queen Mary University of London , London , UK
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26
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Komatsu J, Mogami A, Iwase H, Obayashi O, Kaneko K. A complete posterior tibial stress fracture that occurred during a middle-distance running race: a case report. Arch Orthop Trauma Surg 2019; 139:25-33. [PMID: 30194512 PMCID: PMC6342873 DOI: 10.1007/s00402-018-3035-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Indexed: 10/28/2022]
Abstract
Posterior tibial stress fractures are more frequent than anterior tibial stress fractures, and they are considered to have a good prognosis for returning to sports; cases leading to a complete fracture are rare. A 17-year-old male involved in high school athletics middle-distance running had a 3-week history of pain with training. He was running up to 300 km/week on streets and cross-country in an even distribution. He had posterior tibial stress fractures, but despite the lower leg pain, he continued running. One year later, he was brought to the emergency department after having sustained an injury to the right lower leg while running in a middle-distance race; bilateral tibial stress fractures, with one side complete and the opposite side incomplete, had developed simultaneously. This relatively rare case of bilateral posterior stress fractures, with one side a complete fracture and the opposite side an incomplete fracture, that was treated surgically via exchange intramedullary nailing is reported. The patient could begin light jogging from 3 months after surgery and was without symptoms at 5 months after surgery. He could resume middle-distance racing after 1 year. Posterior tibial cortical fractures are more common and respond better to conservative treatment than anterior tibial stress fractures, and they are a common fracture type in runners. We believe that close, careful follow-up is necessary if patients continue excessive training.
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Affiliation(s)
- Jun Komatsu
- 0000 0004 1762 2738grid.258269.2Departments of Medicine for Motor Organs, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Atsuhiko Mogami
- grid.482667.9Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, 410-2295 Shizuoka Japan
| | - Hideaki Iwase
- 0000 0004 1762 2738grid.258269.2Department of Bio-Engineering, Juntendo University Institute of Casualty Center, 1129 Nagaoka, Izunokuni, 410-2295 Shizuoka Japan
| | - Osamu Obayashi
- grid.482667.9Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, 410-2295 Shizuoka Japan
| | - Kazuo Kaneko
- 0000 0004 1762 2738grid.258269.2Departments of Medicine for Motor Organs, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
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27
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Shaner AC, Spiker AM, Goolsby MA, Kelly BT, Helfet DL. Case report: ischial stress fracture non-union in a college football player. J Hip Preserv Surg 2018; 5:312-318. [PMID: 30393560 PMCID: PMC6206699 DOI: 10.1093/jhps/hny019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/19/2018] [Indexed: 12/31/2022] Open
Abstract
Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.
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Affiliation(s)
- Adam C Shaner
- Department of Orthopaedic Surgery, Trauma Surgery, Westchester Medical Center, New York Medical College, NY, USA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, Sports Medicine and Hip Preservation, University of Wisconsin – Madison, Madison, WI, USA
| | | | - Bryan T Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David L Helfet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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28
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Miller TL, Jamieson M, Everson S, Siegel C. Expected Time to Return to Athletic Participation After Stress Fracture in Division I Collegiate Athletes. Sports Health 2017; 10:340-344. [PMID: 29240544 PMCID: PMC6044125 DOI: 10.1177/1941738117747868] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Few studies have documented expected time to return to athletic participation after stress fractures in elite athletes. HYPOTHESIS Time to return to athletic participation after stress fractures would vary by site and severity of stress fracture. STUDY DESIGN Retrospective cohort study. LEVEL OF EVIDENCE Level 3. METHODS All stress fractures diagnosed in a single Division I collegiate men's and women's track and field/cross-country team were recorded over a 3-year period. Site and severity of injury were graded based on Kaeding-Miller classification system for stress fractures. Time to return to full unrestricted athletic participation was recorded for each athlete and correlated with patient sex and site and severity grade of injury. RESULTS Fifty-seven stress fractures were diagnosed in 38 athletes (mean age, 20.48 years; range, 18-23 years). Ten athletes sustained recurrent or multiple stress fractures. Thirty-seven injuries occurred in women and 20 in men. Thirty-three stress fractures occurred in the tibia, 10 occurred in the second through fourth metatarsals, 3 occurred in the fifth metatarsal, 6 in the tarsal bones (2 navicular), 2 in the femur, and 5 in the pelvis. There were 31 grade II stress fractures, 11 grade III stress fractures, and 2 grade V stress fractures (in the same patient). Mean time to return to unrestricted sport participation was 12.9 ± 5.2 weeks (range, 6-27 weeks). No significant differences in time to return were noted based on injury location or whether stress fracture was grade II or III. CONCLUSION The expected time to return to full unrestricted athletic participation after diagnosis of a stress fracture is 12 to 13 weeks for all injury sites. CLINICAL RELEVANCE Athletes with grade V (nonunion) stress fractures may require more time to return to sport.
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Affiliation(s)
| | | | | | - Courtney Siegel
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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29
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Schwartz O, Abdallah S, Kutikov S, Olsen CH, Dudkiewicz I. The Prevalence and Body Site Distribution of Stress Fractures among Female Combat Soldiers in the Israeli Defense Forces: A Cross-Sectional Study. GENDER AND THE GENOME 2017. [DOI: 10.1089/gg.2017.0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
One of the most troublesome overuse injuries is stress fractures, for which female gender is a major risk factor. In 2015, the Israeli government opened identical combat duties for both genders. The purpose of this study is to provide a detailed report regarding the prevalence and characteristics of stress fractures in females that will serve as an evidence-based platform for future policy planning and implementation regarding female integration in combat units. This is a report of a cross-sectional study of 2223 female soldiers recruited to combat units between 2010 and 2013. Data were collected from the Israeli Defense Force's (IDF's) computerized medical consultation records package. Descriptive and analytic statistics were performed to obtain and analyze results. The overall stress fractures rate was 11.6% (258 soldiers). The most frequent site for stress fracture was the distal tibia (215 cases, 83%). The average lost training days due to a stress fracture were 26.6 days. The risk for developing a stress fracture was 2.15 (215%) times higher in the noninfantry group than in the infantry group, ( p = 0.0232, 95% confidence interval 1.346, 4.536). The rate of stress fractures and the consequent lost training days in the IDF are high and necessitate the planning and implementation of a comprehensive intervention policy to reduce overuse injuries and stress fracture rates among female warriors.
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Affiliation(s)
| | | | | | - Cara H. Olsen
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Israel Dudkiewicz
- Department of Rehabilitation, Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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30
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Cox T, Sneed T, Hamann H. Neurodynamic mobilization in a collegiate long jumper with exercise-induced lateral leg and ankle pain: A case report. Physiother Theory Pract 2017; 34:241-249. [PMID: 28937849 DOI: 10.1080/09593985.2017.1377793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY DESIGN Case Report. BACKGROUND The purpose of this case report is to describe nerve mobilization in the treatment of lower extremity neuropathic pain in a female collegiate long jumper. CASE DESCRIPTION A 21 year-old long jumper presented 7 months after onset of ankle and leg pain. She complained of "aching" pain over the lateral ankle, radiating proximally to just superior to the lateral knee. Neurodynamic testing of the sural and superficial branch of the fibular nerves was positive. Interventions/Outcomes: Persistent neuropathic pain which impeded sport participation in a collegiate athlete did not improve using traditional rehabilitation intervention, but did ameliorate as a result of an intervention which included self-administered, supervised nerve mobilization of the sural and superficial branch of fibular nerve. The patient improved in all outcome measures including the Lower Extremity Functional Scale (LEFS), Numerical Pain Rating Scale (NPRS), and the Global Rating of Change (GROC). DISCUSSION In a female collegiate athlete with persistent neuropathic pain, initial improvements were achieved with traditional rehabilitation, but her pain continued. Considerable additional improvements were achieved following the addition of self-administered, supervised nerve mobilization. Neurodynamic testing should be performed on patients with possible peripheral nerve involvement and treatment commenced if positive.
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Affiliation(s)
- Terry Cox
- a Department of Physical Therapy , Southwest Baptist University , Bolivar , MO , USA
| | - Tom Sneed
- a Department of Physical Therapy , Southwest Baptist University , Bolivar , MO , USA
| | - Herb Hamann
- a Department of Physical Therapy , Southwest Baptist University , Bolivar , MO , USA
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31
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Duignan M, O'Connor N. Female athlete triad: At breaking point. Int Emerg Nurs 2017; 34:51-54. [PMID: 28442226 DOI: 10.1016/j.ienj.2017.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/26/2017] [Indexed: 11/20/2022]
Affiliation(s)
| | - Niall O'Connor
- Our Lady's Hospital, Navan, Ireland; Our Lady of Lourdes Hospital, Drogheda, Ireland
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32
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Robertson GAJ, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop 2017; 8:242-255. [PMID: 28361017 PMCID: PMC5359760 DOI: 10.5312/wjo.v8.i3.242] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/14/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.
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33
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Robertson GA, Wood AM. Femoral Neck Stress Fractures in Sport: A Current Concepts Review. Sports Med Int Open 2017; 1:E58-E68. [PMID: 30539087 PMCID: PMC6226070 DOI: 10.1055/s-0043-103946] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 12/11/2022] Open
Abstract
Femoral neck stress fractures (FNSFs) account for 3% of all sport-related stress fractures. The commonest causative sports are marathon and long-distance running. The main types of FNSF are compression-sided, tension-sided and displaced. The most common reported symptom is exercise-related groin pain. Radiographs form the first line of investigation, with MRI the second-line investigation. The management of FNSFs is guided by the location and displacement of the fracture. Delay in diagnosis is common and increases the likelihood of fracture displacement. Sporting outcomes are considerably worse for displaced fractures. Education programmes and treatment protocols can reduce the rates of displaced FNSFs. This article aims to provide a current concepts review on the topic of FNSFs in sport, assess the current evidence on the epidemiology and pathophysiology of these injuries, detail the current recommendations for their imaging and management, and review the recorded sporting outcomes for FNSFs in the existing literature. From this study, we conclude that although FNSFs are a rare injury, they should be considered in all athletes presenting with exercise-related hip pain, because delay in diagnosis and subsequent fracture displacement can significantly impair future return to sport. However, when detected early, FNSFs show promising results in terms of return-to-sport rates and times.
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Affiliation(s)
- Greg A Robertson
- Edinburgh Orthopaedic Trauma Unit, Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - Alexander M Wood
- Bristol Royal Infirmary, Department of Orthopaedics, Bristol, United Kingdom of Great Britain and Northern Ireland
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34
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Nye NS, Covey CJ, Sheldon L, Webber B, Pawlak M, Boden B, Beutler A. Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries. Sports Health 2017; 8:278-283. [PMID: 26945021 PMCID: PMC4981068 DOI: 10.1177/1941738116635558] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
CONTEXT Lower extremity stress fractures among athletes and military recruits cause significant morbidity, fiscal costs, and time lost from sport or training. During fiscal years (FY) 2012 to 2014, 1218 US Air Force trainees at Joint Base San Antonio-Lackland, Texas, were diagnosed with stress fracture(s). Diagnosis relied heavily on bone scans, often very early in clinical course and often in preference to magnetic resonance imaging (MRI), highlighting the need for an evidence-based algorithm for stress injury diagnosis and initial management. EVIDENCE ACQUISITION To guide creation of an evidence-based algorithm, a literature review was conducted followed by analysis of local data. Relevant articles published between 1995 and 2015 were identified and reviewed on PubMed using search terms stress fracture, stress injury, stress fracture imaging, and stress fracture treatment. Subsequently, charts were reviewed for all Air Force trainees diagnosed with 1 or more stress injury in their outpatient medical record in FY 2014. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS In FY 2014, 414 trainees received a bone scan and an eventual diagnosis of stress fracture. Of these scans, 66.4% demonstrated a stress fracture in the symptomatic location only, 21.0% revealed stress fractures in both symptomatic and asymptomatic locations, and 5.8% were negative in the symptomatic location but did reveal stress fracture(s) in asymptomatic locations. Twenty-one percent (18/85) of MRIs performed a mean 6 days (range, 0- 21 days) after a positive bone scan did not demonstrate any stress fracture. CONCLUSION Bone stress injuries in military training environments are common, costly, and challenging to diagnose. MRI should be the imaging study of choice, after plain radiography, in those individuals meeting criteria for further workup.
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Affiliation(s)
- Nathaniel S. Nye
- 559th Trainee Health Squadron, Joint Base San Antonio–Lackland, Texas
| | - Carlton J. Covey
- Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lucas Sheldon
- 59th Radiology Squadron, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio–Lackland, Texas
| | - Bryant Webber
- 559th Trainee Health Squadron, Joint Base San Antonio–Lackland, Texas
| | - Mary Pawlak
- 559th Trainee Health Squadron, Joint Base San Antonio–Lackland, Texas
| | | | - Anthony Beutler
- Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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35
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High-Risk Stress Fractures: Diagnosis and Management. PM R 2017; 8:S113-24. [PMID: 26972260 DOI: 10.1016/j.pmrj.2015.09.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 09/22/2015] [Accepted: 09/25/2015] [Indexed: 12/11/2022]
Abstract
Stress fractures are common overuse injuries in athletes. They occur during periods of increased training without adequate rest, disrupting normal bone reparative mechanisms. There are a host of intrinsic and extrinsic factors, including biochemical and biomechanical, that put athletes at risk. In most stress fractures, the diagnosis is primarily clinical, with imaging indicated at times, and management focused on symptom-free relative rest with advancement of activity as tolerated. Overall, stress fractures in athletes have an excellent prognosis for return to sport, with little risk of complication. There is a subset of injuries that have a greater risk of fracture progression, delayed healing, and nonunion and are generally more challenging to treat with nonoperative care. Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites share a characteristic region of high tensile load and low blood flow. High-risk stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment. Treatment consists of nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity. These stress fractures may require surgical intervention. A high index of suspicion is essential to avoid delayed diagnosis and optimize outcomes in this subset of stress fractures.
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36
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Miller TL, Best TM. Taking a holistic approach to managing difficult stress fractures. J Orthop Surg Res 2016; 11:98. [PMID: 27608681 PMCID: PMC5016928 DOI: 10.1186/s13018-016-0431-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/17/2016] [Indexed: 01/30/2023] Open
Abstract
Stress fractures and other bony stress injuries occur along a spectrum of severity which can impact treatment and prognosis. When treating these injuries, it should be borne in mind that no two stress fractures behave exactly alike. Given that they are not a consistent injury, standardized treatment protocols can be challenging to develop. Treatment should be individualized to the patient or athlete, the causative activity, the anatomical site, and the severity of the injury. A holistic approach to the treatment of the most difficult stress fractures should be taken by orthopedists and sports medicine specialists. This approach is necessary to obtain optimal outcomes, minimize loss of fitness and time away from sports participation, and decrease the risk of recurrence.
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Affiliation(s)
- Timothy L. Miller
- Orthopaedic Surgery and Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
- Capital University Athletics, 920 North Hamilton Road, Suite 600, Gahanna, OH 43230 USA
| | - Thomas M. Best
- Academic Affairs, Department of Family Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
- Biomedical Engineering, The Ohio State University, Columbus, OH USA
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Casagranda BU, Thurlow PC. The Role of Imaging in Determining Return to Play. Radiol Clin North Am 2016; 54:979-88. [DOI: 10.1016/j.rcl.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ramey LN, McInnis KC, Palmer WE. Femoral Neck Stress Fracture: Can MRI Grade Help Predict Return-to-Running Time? Am J Sports Med 2016; 44:2122-9. [PMID: 27261475 DOI: 10.1177/0363546516648319] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Limited research is available regarding return-to-running (RTR) time after femoral neck stress fractures. While studies have shown the prognostic value of image-based grading scales for stress fractures at other sites, few have included femoral neck stress fractures. PURPOSE To determine if the grade of femoral neck stress fractures based on magnetic resonance imaging (MRI) characteristics correlates with RTR time. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This study included 24 patients (mean age, 32.9 years; range, 18-51 years) who were diagnosed with 27 femoral neck stress fractures by MRI from 2009 to 2015 at a single sports medicine clinic. All fractures were compression sided and were treated nonoperatively. Charts were reviewed for patient demographics and RTR time. Images were graded from 1 to 4 using the Arendt stress fracture severity scale. Statistical analysis was performed using survival analysis and Cox proportional hazard model to compare the RTR time between grades. Cox regression was repeated, adjusted for age, bone mineral density (BMD), and body mass index (BMI). RESULTS The mean (±standard error of the mean) RTR time in weeks for patients with fractures graded 1 to 4 was 7.4 ± 2.7 (range, 4-11), 13.8 ± 3.8 (range, 6-21), 14.7 ± 3.5 (range, 8.5-24), and 17.5 ± 3.4 (range, 10-32), respectively. Survival analysis indicated that there was a statistically significant effect of fracture grade on RTR time (P = .0065). The Cox model indicated a statistically significant difference in RTR time between grades 1 and 2 (P = .036), 1 and 3 (P = .014), and 1 and 4 (P = .002). The unadjusted hazard ratio was significant (P = .037). There were no statistically significant differences between the remaining grades (P = .82 for grades 2 and 3, P = .37 for grades 2 and 4, and P = .31 for grades 3 and 4). Age (P = .71) and BMD (P = .81) did not have an effect on RTR time. The hazard ratio remained significant (P = .05) after adjusting for age and BMD. BMI tended to have an effect on RTR time (P = .09). After adding BMI to the adjustment, the hazard ratio decreased in significance (P = .13), although sample size also decreased. CONCLUSION Grade 2 to 4 femoral neck stress fractures require longer RTR time than do grade 1 injuries. Patients with lower BMI tend to require a longer RTR time.
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Affiliation(s)
- Lindsay N Ramey
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA Harvard Medical School, Cambridge, Massachusetts, USA
| | - Kelly C McInnis
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA Harvard Medical School, Cambridge, Massachusetts, USA Division of Orthopedics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William E Palmer
- Harvard Medical School, Cambridge, Massachusetts, USA Division of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Markolf KL, Cheung E, Joshi NB, Boguszewski DV, Petrigliano FA, McAllister DR. Plate Versus Intramedullary Nail Fixation of Anterior Tibial Stress Fractures: A Biomechanical Study. Am J Sports Med 2016; 44:1590-6. [PMID: 26944573 DOI: 10.1177/0363546516631745] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior midtibial stress fractures are an important clinical problem for patients engaged in high-intensity military activities or athletic training activities. When nonoperative treatment has failed, intramedullary (IM) nail and plate fixation are 2 surgical options used to arrest the progression of a fatigue fracture and allow bone healing. HYPOTHESIS A plate will be more effective than an IM nail in preventing the opening of a simulated anterior midtibial stress fracture from tibial bending. STUDY DESIGN Controlled laboratory study. METHODS Fresh-frozen human tibias were loaded by applying a pure bending moment in the sagittal plane. Thin transverse saw cuts, 50% and 75% of the depth of the anterior tibial cortex, were created at the midtibia to simulate a fatigue fracture. An extensometer spanning the defect was used to measure the fracture opening displacement (FOD) before and after the application of IM nail and plate fixation constructs. IM nails were tested without locking screws, with a proximal screw only, and with proximal and distal screws. Plates were tested with unlocked bicortical screws (standard compression plate) and locked bicortical screws; both plate constructs were tested with the plate edge placed 1 mm from the anterior tibial crest (anterior location) and 5 mm posterior to the crest. RESULTS For the 75% saw cut depth, the mean FOD values for all IM nail constructs were 13% to 17% less than those for the saw cut alone; the use of locking screws had no significant effect on the FOD. The mean FOD values for all plate constructs were significantly less than those for all IM nail constructs. The mean FOD values for all plates were 28% to 46% less than those for the saw cut alone. Anterior plate placement significantly decreased mean FOD values for both compression and locked plate constructs, but the mean percentage reductions for locked and unlocked plates were not significantly different from each other for either plate placement. The percentage FOD reductions for all plate constructs and the unlocked IM nail were significantly less with a 50% saw cut depth. CONCLUSION Plate fixation was superior to IM nail fixation in limiting the opening of a simulated midtibial stress fracture, and anterior-posterior placement of the plate was an important variable for this construct. CLINICAL RELEVANCE Results from these tests can help guide the selection of fixation hardware for patients requiring surgical treatment for a midtibial stress fracture.
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Affiliation(s)
- Keith L Markolf
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Edward Cheung
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nirav B Joshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Daniel V Boguszewski
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Frank A Petrigliano
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David R McAllister
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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D'Hooghe P, Wiegerinck JI, Tol JL, Landreau P. Answer to ‘A 22-year-old professional soccer player with atraumatic ankle pain’. Br J Sports Med 2015. [DOI: 10.1136/bjsports-2013-092579a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hattori H, Ito T. Recurrent Fracture After Anterior Tension Band Plating With Bilateral Tibial Stress Fracture in a Basketball Player: A Case Report. Orthop J Sports Med 2015; 3:2325967115610069. [PMID: 26535378 PMCID: PMC4622293 DOI: 10.1177/2325967115610069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hiroyuki Hattori
- Department of Orthopedic Surgery, Japan Community Health Care Organization, Tokyo Kamata Medical Center, Ohta-ku, Tokyo, Japan
| | - Toshiyuki Ito
- Department of Orthopedic Surgery, Japan Community Health Care Organization, Tokyo Kamata Medical Center, Ohta-ku, Tokyo, Japan
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Weel H, Mallee WH, van Dijk CN, Blankevoort L, Goedegebuure S, Goslings JC, Kennedy JG, Kerkhoffs GMMJ. The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial. BMC Musculoskelet Disord 2015; 16:211. [PMID: 26290323 PMCID: PMC4546041 DOI: 10.1186/s12891-015-0649-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 07/27/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. METHODS/DESIGN A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent. DISCUSSION This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. TRIAL REGISTRATION Netherlands Trial Register (reg.nr NTR4377 ).
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Affiliation(s)
- Hanneke Weel
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - Wouter H Mallee
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - Leendert Blankevoort
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - Simon Goedegebuure
- The Sport Physician Group, Saint Lucas Andreas Hospital department of Sports Medicine, Jan Tooropstraat 164, 1061, AE, Amsterdam, The Netherlands.
| | - J Carel Goslings
- Department of Surgery, Trauma Unit, Academical Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - John G Kennedy
- Orthopaedic Surgery, Hospital for Special Surgery, 523 East 72nd Street, 5th Floor Rm 514, New York, NY, 10021, USA.
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
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Abstract
Clinical diagnostic tests objectively evaluate lower extremity ailments of the athlete. The positive squeeze test is found to be reproducible for ankle syndesmotic injury but is a poor prognosticator. The anterior drawer and talar tilt tests assess lateral ankle sprains. These have limitations secondary to positioning and guarding by the athlete, so comparison with the asymptomatic extremity is recommended. The Ottawa ankle rules assess possible fractures of the ankle and midfoot. The Thompson test evaluates Achilles tendon tears, whereas the windlass technique and the modified Lachman test examine the integrity of the plantar fascia and metatarsophalangeal joint capsule.
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Affiliation(s)
- Alex Kor
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
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Changstrom BG, Brou L, Khodaee M, Braund C, Comstock RD. Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012-2013. Am J Sports Med 2015; 43:26-33. [PMID: 25480834 DOI: 10.1177/0363546514562739] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND High school athletes in the United States sustain millions of injuries annually, approximately 10% of which are fractures. However, there is no clear estimate of the number of stress fractures sustained by high school athletes annually despite reports that stress fractures account for 0.7% to 20% of injuries seen in sports medicine clinics. This suggests a high utilization of resources for a potentially preventable injury. In addition, stress fractures have been associated with low energy availability and disordered eating in young athletes, highlighting the importance of early recognition and intervention. PURPOSE To investigate stress fracture rates and patterns in a large national sample of US high school athletes. STUDY DESIGN Descriptive epidemiologic study. METHODS Data from High School RIO (Reporting Information Online), a national sports injury surveillance study, were analyzed to describe rates and patterns of stress fracture injury sustained from 2005-2006 through 2012-2013, across sports and by sex. RESULTS From 2005-2006 through 2012-2013, a total of 51,773 injuries were sustained during 25,268,873 athlete-exposures, of which 389 (0.8%) were stress fractures, resulting in an overall stress fracture rate of 1.54 per 100,000 athlete-exposures. Rates per 100,000 athlete-exposures were highest in girls' cross country (10.62), girls' gymnastics (7.43), and boys' cross country (5.42). In sex-comparable sports, girls sustained more stress fractures (63.3%) than did boys (36.7%) and had higher rates of stress fracture (2.22 vs 1.27; rate ratio, 1.75; 95% CI, 1.38-2.23). The most commonly injured sites were the lower leg (40.3% of all stress fractures), foot (34.9%), and lower back/lumbar spine/pelvis (15.2%). Management was nonsurgical in 98.7% of the cases, and 65.3% of injuries resulted in ≥3 weeks of time loss, medical disqualification, or an end to the season before athletes could return to play. CONCLUSION Although a rare injury, stress fractures cause considerable morbidity for high school athletes of both sexes. Future research should evaluate risks of stress fractures to drive development of targeted prevention efforts.
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Affiliation(s)
- Bradley G Changstrom
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lina Brou
- Department of Emergency Medicine, The Children's Hospital Colorado, Aurora, Colorado, USA Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Morteza Khodaee
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cortney Braund
- Department of Emergency Medicine, The Children's Hospital Colorado, Aurora, Colorado, USA
| | - R Dawn Comstock
- Department of Epidemiology and Pediatric Injury Prevention, Education and Research (PIPER) Program, Colorado School of Public Health, Aurora, Colorado, USA
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Jain N, Murray D, Kemp S, Calder J. Frequency and trends in foot and ankle injuries within an English Premier League Football Club using a new impact factor of injury to identify a focus for injury prevention. Foot Ankle Surg 2014; 20:237-40. [PMID: 25457658 DOI: 10.1016/j.fas.2014.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/03/2014] [Accepted: 05/08/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Foot and ankle injuries are common in football. Prevention strategies exist in order to decrease the incidence of such injuries and minimize the number of days that a player is unavailable for selection. METHODS Injuries were recorded over a 4-season period while the team was playing in the English Premier League (EPL). We present the epidemiology of foot and ankle injuries within a professional football club and offer a calculation that may be of use in the future to identify areas of injury prevention. RESULTS Anterior Talo-Fibular Ligament (ATFL) injuries and fifth metatarsal fractures were of high impact as they were both common and resulted in significant time periods where the player was unavailable. CONCLUSIONS This is the first time an EPL club has been prepared to publish data regarding injury. Our findings may be used by others to focus their prevention strategies on the injuries with the highest impact.
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Affiliation(s)
- Neil Jain
- Joint Preservation Centre, University of British Columbia, Wesbrook Mall, Vancouver, British Columbia V6T 2B5, Canada.
| | - David Murray
- Department of Trauma & Orthopaedics, Stepping Hill Hospital, Poplar Grove, Stockport, Cheshire SK2 7JE, United Kingdom
| | - Steve Kemp
- The Football Association, St George's Park, Newborough Road, Needwood, Burton Upon Trent, Staffordshire DE13 9PD, United Kingdom
| | - James Calder
- Department of Trauma & Orthopaedics, Chelsea & Westminster Hospital, Fulham Road, London SW10 9NH, United Kingdom
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Graham EM, Burns J, Hiller CE, Nightingale EJ, Simic M. Management for common lower leg stress fractures in athletes. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/1743288x14y.0000000158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Irion V, Miller TL, Kaeding CC. The treatment and outcomes of medial malleolar stress fractures: a systematic review of the literature. Sports Health 2014; 6:527-30. [PMID: 25364485 PMCID: PMC4212354 DOI: 10.1177/1941738114546089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Context: The medial malleolus is considered a high-risk stress fracture and can be debilitating to the highly active or athletic populations. A range of treatment methods have been described with varying outcomes. Currently, there is no gold standard treatment option with optimal results described. Objective: A systematic search of the literature to determine treatment options and outcomes in medial malleolus stress fractures. Data Sources: OVID/Medline, EMBASE, and the Cochrane Library from 1950 to September 2013. Study Selection: Included studies mentioned treatment and outcomes of medial malleolus stress fractures. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: The searches used combinations of the terms stress fracture, medial malleolus, management, and treatment. Two authors independently reviewed the selected articles and created individual tables, which were later compiled into a master table for final analysis. Results: Six retrospective case series were identified (n = 31 patients). Eighty percent (25/31) of patients were men, with an average age of 24.5 years. Ninety percent (28/31) of patients were at least involved in recreational athletics. All patients were able to return to sport. Complications were seen in both groups ranging from minor stiffness to nonunion requiring open reduction internal fixation. Conclusion: Nonoperative and operative interventions have proven to be successful with regard to healing and return to play for medial malleolar stress fractures in the recreational and competitive athlete. However, early operative intervention can possibly create a higher likelihood of early healing, decrease in symptoms, and return to play.
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Affiliation(s)
- Val Irion
- OSU Sports Medicine, Sports Health and Performance Institute, The Ohio State University, Columbus, Ohio
| | - Timothy L Miller
- OSU Sports Medicine, Sports Health and Performance Institute, The Ohio State University, Columbus, Ohio ; Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Christopher C Kaeding
- OSU Sports Medicine, Sports Health and Performance Institute, The Ohio State University, Columbus, Ohio ; Department of Orthopaedics, The Ohio State University, Columbus, Ohio
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Abstract
OBJECTIVE To evaluate the effectiveness of low-intensity pulsed ultrasound (LIPUS) for the improvement of lower limb bone stress injuries in a civilian population. DESIGN A prospective, randomized, double-blinded, placebo-controlled trial to compare LIPUS with placebo. SETTING Civilian private practice population in Sydney, Australia. PARTICIPANTS Subjects were recruited if a grade II-IV bone stress injury was diagnosed on magnetic resonance imaging (MRI) of either the postero-medial tibia, fibula or second, third, or fourth metatarsal. Subjects of all levels of sporting activity were included. Thirty subjects were initially recruited, and 23 subjects were included in the final analysis. INTERVENTIONS Subjects were randomized into either the treatment or placebo arm and matched to the site of injury (tibia, fibula, or metatarsal). Subjects in both arms used either treatment or placebo devices for 20 minutes daily for 4 weeks. MAIN OUTCOME MEASURES Six clinical parameters (night pain, pain at rest, pain on walking, pain with running, tenderness, and pain with single leg hop) were compared before and after intervention. The changes in MRI grade and bone marrow edema size were also compared. RESULTS There were no significant differences between the treatment and placebo conditions for changes in MRI grading (2.2 vs 2.4, P = 0.776) or bone marrow edema size (3 vs 4.1, P = 0.271). There were no significant differences between the treatment and placebo conditions for the 6 clinical parameters. CONCLUSIONS Low-intensity pulsed ultrasound was found not to be an effective treatment for the healing of lower limb bone stress injuries in this study. However, this was measured over a relatively short duration of 4 weeks in a small, mostly female population. CLINICAL RELEVANCE This double-blinded, randomized, placebo-controlled trial has shown that LIPUS is not an effective treatment for lower limb bone stress injuries.
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Pegrum J, Dixit V, Padhiar N, Nugent I. The pathophysiology, diagnosis, and management of foot stress fractures. PHYSICIAN SPORTSMED 2014; 42:87-99. [PMID: 25419892 DOI: 10.3810/psm.2014.11.2095] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION There is an increasing prevalence of osteoporosis, and with it a rise in the diagnosis of stress fractures. Postmenopausal women are particularly at risk of stress fractures. This review article describes the pathophysiology of foot stress fractures and the latest diagnostic and treatment strategies for these common injuries. DISCUSSION There are numerous risk factors for stress fractures that have been identified in the literature. Reduced bone mineral density is an independent risk factor for delayed union. Prevention of stress fractures with training periodization and nutritional assessment is essential, especially in females. Diagnosis of stress fractures of the foot is based on history and diagnostic imaging, which include radiographs, ultrasound, therapeutic ultrasound, computed tomography, and bone scans; however, magnetic resonance imaging is still the gold standard. Treatment depends on the bone involved and the risk of nonunion, with high-risk fractures requiring immobilization or surgical intervention. Patients presenting with underlying bone mineral deficiency treated without surgery require a longer period of activity modification. Training rehabilitation protocols are described for those with low-risk stress fractures. RESULTS A useful algorithm is presented to guide the clinician in the diagnosis and management of such injuries.
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Affiliation(s)
- James Pegrum
- Oxford John Radcliffe Hospitals Orthopaedic Trauma Rotation, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, England.
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Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CWC. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med 2014; 49:370-6. [PMID: 25138980 DOI: 10.1136/bjsports-2013-093246] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. METHODS Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective studies. Two reviewers independently extracted data and assessed methodological quality. Main outcomes were return to sport and complication rate. RESULTS 18 studies were included (2 anterior tibia (N=31), 8 navicular (N=200) and 8 fifth metatarsal (N=246)). For anterior tibial fracture, no studies on initial surgery were eligible. Conservative treatment resulted in high complication rates and few cases returned to sport. For navicular fracture, a weighted mean return to sport of 22 for conservative and 16 weeks for surgical treatment was found. Six weeks of non-weightbearing cast was mostly used as conservative treatment. Surgical procedures varied widely. For the fifth metatarsal fracture, weighted mean return to sport was 19 for conservative and 14 weeks for surgical treatment. Surgery consisted of intramedullary screw fixation or tension band wiring. For conservative methods, insufficient details were reported. Overall, there was a high risk of bias; sample sizes were small and GRADE level of evidence was low. CONCLUSIONS Strong conclusions for surgical or conservative therapy for these high-risk stress fractures cannot be drawn; quality of evidence is low and subjected to a high risk of bias. However, there are unsatisfying outcomes of conservative therapy in the anterior tibia. The role of initial surgery is unknown. For the navicular, surgery provided an earlier return to sport; and when treated conservatively, weightbearing should be avoided. For the fifth metatarsal, surgery provided the best results. Treatment decision-making would greatly benefit from further prospective research. STUDY REGISTRATION NUMBER PROSPERO database of systematic reviews: CRD42013004201.
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Affiliation(s)
- Wouter H Mallee
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke Weel
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department Health Sciences, EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Gino M Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Chung-Wei Christine Lin
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
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